Dr. Ravi Hira is a well-published interventional cardiologist specializing in complex coronary disease, offering treatment options for patients who may not be surgical candidates. Dr. Hira currently practices at the Pulse Heart Institute and serves as Director of the Cardiac Care Outcomes Assessment Program (COAP) in Seattle, WA. In this interview, Dr. Hira shares his journey in the field of medicine with an emphasis on personal growth, autonomy, community, and passion for his work.
Shortly after you completed your fellowship training, was there a therapy area or subject matter you wish you were taught or had more experience in?
It’s been almost 10 years since I graduated in 2015, and a lot has changed since then.
I trained in Houston, Texas, a city heavily focused on surgical treatment of complex CAD. So we didn't really do much complex percutaneous coronary interventions (PCI), to be honest. I had a bit of exposure to atherectomy and some Impella and mechanical circulatory support, but only very minimal exposure to chronic total occlusions (CTOs) or complex coronary training. The more complex cases were typically referred to surgery, and surgeons were quite aggressive in taking those on. Then, when I moved to Washington for my first job post-training, I noticed that we were dealing with an older patient population, many over 70 or 80, who were being turned down for surgery. These patients ended up in our care, which meant I had to really step up my skills in complex coronary procedures.
Although I had attended conferences and meetings where these cases were discussed and demonstrated, I didn’t have much first-hand experience with them myself. It was only when I began practicing that I fully realized the extent of this gap in my experience.
I found myself looking at cases that, during my training, would have been referred to surgery – but now, these cases were being sent back to us, either not fully treated or simply turned down by surgeons. It brought me to a crucial question: what should I do with these patients, and how could I enhance my skills to serve them better?
If I'm a fellow nearing the end of training or early in my career, what are one or two immediate steps I can take to steepen my learning curve in complex PCI?
Back in 2015, when I was getting into this, the term “complex PCI” wasn’t widely recognized. CHIP was just emerging, but things are very different now. Back then, online resources – like Twitter for example – weren’t readily available with this kind of information. There wasn’t a dedicated fellowship or specialized training in complex coronary work. I learned a lot of this on the job later in my career. There was a growing awareness of the diversification in interventional cardiology, with many leaning towards structural work. Quite a few of my co-fellows chose to pursue structural cardiology directly in their jobs. At the time, the focus was more on procedures like TAVR, but discussions about Mitral procedures were not as common. There was a sentiment that if you've already been trained, why spend another year on complex coronary?
Having seen the range and complexity of what can be done now, I’d say considering an additional year of training could be beneficial. If not, finding a role that offers on-the-job exposure with good mentorship is invaluable. It’s something I was lucky to stumble upon, although it wasn’t preplanned. Additionally, attending more meetings and actively engaging with the medical community is key. There’s a lot more visibility now about what others are doing, thanks to Twitter and live case streams or recorded procedures – where I learned a lot of tips and tricks. This access makes it easier to learn and apply new techniques. In the past, our network was limited to a handful of colleagues for case discussions. Now, you can reach out to a global community for feedback and advice, which is an incredible resource.
Many residents and fellows leave training with a sense that they aren’t fully ready for clinical practice. Do you remember a time when you felt like you weren’t prepared for “prime time”? How did you overcome this?
That’s a relatable feeling. When I finished my training, I certainly felt unprepared, beyond just the initial jitters of starting as a new attending. It was compounded by the responsibility of training fellows. It was challenging to balance guiding them while giving them enough freedom to learn through their own mistakes—as a result, in my early days as an attending, my evaluations weren’t that great. To be frank, I was seen as overly hands-on compared to more experienced colleagues who were just sitting in the control room and letting the fellows do what they do. I was the only interventionalist and cath lab director at my primary hospital, so it was a bit isolating without peers to consult on-site. In other words, if there was a complication, it was on me.
What helped me was talking to others and reaching out for help – it's an experience which everybody goes through in many different ways. I’ve never been one to let ego get in the way of admitting I don’t know something and asking for guidance or help.
Some people come out of training feeling overly confident. They think they are God's gift to interventional cardiology. But that’s fundamentally flawed and gets in their way of growth, evolution and serving their patients, to be honest.
I’m listening to an audio book titled Black Box Thinking by Matthew Syed—it was suggested by my mentor—which compares the airline industry to medicine and illustrates the importance of systematic learning from experiences. If you don't ask someone else to look at your case or to review things, you never get feedback. You can critique yourself only up to a point. For example, in the first few months after a few of my fellows graduated, they would call me on every complex case, then it gradually got less and less until they felt comfortable finding someone local or managing cases by themselves. And the good thing is, nowadays, it’s easier to connect with a community for support and advice than it was before. I think that doing my best to rely on a support network and not letting judgment or ego cloud my vision played an important role in my journey.
It’s also crucial to focus on the patients’ best interest and acknowledge when your skills might not yet match their needs. Sometimes you’ll need to refer a patient to a colleague who’s more comfortable with their case. Or you can work with them—taking on cases alongside more experienced colleagues, like double scrubbing on complex cases like CTOs, can be incredibly beneficial for both the doctor and the patient. This is my point of view since I moved to private practice a few years ago.
Do you have a go-to algorithm when it comes to treating challenging calcific plaque from an interventional perspective?
Our approach, especially regarding tools, has evolved recently. Intravascular lithotripsy (IVL) has become a significant asset and made certain procedures more easily accessible. The algorithm is essentially the one Dr. Kevin Croce put up on Twitter.
Intravascular imaging is crucial in my practice – it’s used in about 99% of cases, especially with calcified complex lesions. It guides us in assessing lesion length, arc of calcification, and depth. Although I don’t have optical coherence tomography (OCT), which makes depth assessment a bit challenging, I rely on Intravascular Ultrasound (IVUS).
For cases where I can't deliver a balloon, rotational atherectomy (ROTA) is my first step for modifying the lesion. If it’s circumferential calcium, I tend to use IVL. For larger vessels with nodular calcium, I often use more orbital atherectomy, especially in the left main artery or bifurcation. Following atherectomy, I do imaging post-ballooning. Checking results with intracoronary imaging using IVUS is a standard practice for me at the end of the case to confirm appropriate stent expansion and optimization, as we often see patients return with issues in calcified lesions that were not optimally treated.
As an attending working at a practice, unlike when I was a trainee, I follow patients long-term. This ongoing care has shown me how treatments done years ago might require modifications, especially if they’d been done suboptimally. It’s all part of the learning process in medical practice. We often find ourselves modifying earlier work with newer techniques like laser atherectomy, IVL, and in some cases, brachytherapy or even bypass. You realize that there are certain things that you may have done differently had you known what you know now. That's why they call it practice; you’re literally learning from each experience.
When thinking about the business of healthcare, are there a couple of concepts that you wish you understood better coming out of fellowship?
I’ve given this quite a bit of thought. Your perspective shifts over time, and it’s interesting to compare where I am now to where I was ten years ago. I spent about five and a half years in academia and have been in private practice for three years. I think when I came out, I was operating on my survival instincts, both for myself and my patients. I wasn’t thinking much about program development or resource management; those came with time.
In any system, dealing with administrators is inevitable, and no one really teaches you how to navigate those conversations. I think it’s fortunate to have an administrator who is motivated to develop programs. They, from my experience, operate on a two-year cycle, focusing on short-term gains for their specific service line. They’re often looking to move up to the next level after showing some profit or benefit within that period. That's just the way that their cycle goes—and I wasn’t aware of it until much later. This mindset doesn’t usually align with the long-term sustainability of a program. The easiest way in any industry to show profit is by cutting costs, which doesn’t always align with the needs of a healthcare program, like acquiring new technology or equipment. Their decisions are often dictated by the budget, which is randomly, arbitrarily set and governed by the focus of being budget positive, not necessarily on net positivity.
This entire concept was hard for me to accept initially because my primary concern was patient care, which sometimes required expensive resources. It was eye-opening to understand the financial perspective behind decisions like starting an ECMO program. The administrative approach often differs significantly from how I would manage my finances – it's all about the budget within their two-year cycle, not necessarily about what's coming in and going out.
So, understanding the incentives of the people you're working with is critical?
Absolutely. I think in business, having a long-term perspective is key, especially when you're committed to staying in the same practice or city. You're in it for the long haul with your patients, who aren't on a two-year cycle like many administrators. They're more likely on a 10-year cycle or longer. So I think it's important to have transparent, though not confrontational, conversations, understanding where the administrators are coming from while keeping your goals and your patient’s goals in mind. These conversations will help you find a common ground.
However, finding common ground might not lead to immediate results, but it's about making progress, however slow it might be. No negotiation yields everything you want right away. It's a gradual process, slower than most expect coming out of training. So why is it taking so long to make a change? It takes time because people's priorities are different.
Dr. Ravi Hira is a well-published interventional cardiologist specializing in complex coronary disease, offering treatment options for patients who may not be surgical candidates. Dr. Hira currently practices at the Pulse Heart Institute and serves as Director of the Cardiac Care Outcomes Assessment Program (COAP) in Seattle, WA. In this interview, Dr. Hira shares his journey in the field of medicine with an emphasis on personal growth, autonomy, community, and passion for his work.
Shortly after you completed your fellowship training, was there a therapy area or subject matter you wish you were taught or had more experience in?
It’s been almost 10 years since I graduated in 2015, and a lot has changed since then.
I trained in Houston, Texas, a city heavily focused on surgical treatment of complex CAD. So we didn't really do much complex percutaneous coronary interventions (PCI), to be honest. I had a bit of exposure to atherectomy and some Impella and mechanical circulatory support, but only very minimal exposure to chronic total occlusions (CTOs) or complex coronary training. The more complex cases were typically referred to surgery, and surgeons were quite aggressive in taking those on. Then, when I moved to Washington for my first job post-training, I noticed that we were dealing with an older patient population, many over 70 or 80, who were being turned down for surgery. These patients ended up in our care, which meant I had to really step up my skills in complex coronary procedures.
Although I had attended conferences and meetings where these cases were discussed and demonstrated, I didn’t have much first-hand experience with them myself. It was only when I began practicing that I fully realized the extent of this gap in my experience.
I found myself looking at cases that, during my training, would have been referred to surgery – but now, these cases were being sent back to us, either not fully treated or simply turned down by surgeons. It brought me to a crucial question: what should I do with these patients, and how could I enhance my skills to serve them better?
If I'm a fellow nearing the end of training or early in my career, what are one or two immediate steps I can take to steepen my learning curve in complex PCI?
Back in 2015, when I was getting into this, the term “complex PCI” wasn’t widely recognized. CHIP was just emerging, but things are very different now. Back then, online resources – like Twitter for example – weren’t readily available with this kind of information. There wasn’t a dedicated fellowship or specialized training in complex coronary work. I learned a lot of this on the job later in my career. There was a growing awareness of the diversification in interventional cardiology, with many leaning towards structural work. Quite a few of my co-fellows chose to pursue structural cardiology directly in their jobs. At the time, the focus was more on procedures like TAVR, but discussions about Mitral procedures were not as common. There was a sentiment that if you've already been trained, why spend another year on complex coronary?
Having seen the range and complexity of what can be done now, I’d say considering an additional year of training could be beneficial. If not, finding a role that offers on-the-job exposure with good mentorship is invaluable. It’s something I was lucky to stumble upon, although it wasn’t preplanned. Additionally, attending more meetings and actively engaging with the medical community is key. There’s a lot more visibility now about what others are doing, thanks to Twitter and live case streams or recorded procedures – where I learned a lot of tips and tricks. This access makes it easier to learn and apply new techniques. In the past, our network was limited to a handful of colleagues for case discussions. Now, you can reach out to a global community for feedback and advice, which is an incredible resource.
Many residents and fellows leave training with a sense that they aren’t fully ready for clinical practice. Do you remember a time when you felt like you weren’t prepared for “prime time”? How did you overcome this?
That’s a relatable feeling. When I finished my training, I certainly felt unprepared, beyond just the initial jitters of starting as a new attending. It was compounded by the responsibility of training fellows. It was challenging to balance guiding them while giving them enough freedom to learn through their own mistakes—as a result, in my early days as an attending, my evaluations weren’t that great. To be frank, I was seen as overly hands-on compared to more experienced colleagues who were just sitting in the control room and letting the fellows do what they do. I was the only interventionalist and cath lab director at my primary hospital, so it was a bit isolating without peers to consult on-site. In other words, if there was a complication, it was on me.
What helped me was talking to others and reaching out for help – it's an experience which everybody goes through in many different ways. I’ve never been one to let ego get in the way of admitting I don’t know something and asking for guidance or help.
Some people come out of training feeling overly confident. They think they are God's gift to interventional cardiology. But that’s fundamentally flawed and gets in their way of growth, evolution and serving their patients, to be honest.
I’m listening to an audio book titled Black Box Thinking by Matthew Syed—it was suggested by my mentor—which compares the airline industry to medicine and illustrates the importance of systematic learning from experiences. If you don't ask someone else to look at your case or to review things, you never get feedback. You can critique yourself only up to a point. For example, in the first few months after a few of my fellows graduated, they would call me on every complex case, then it gradually got less and less until they felt comfortable finding someone local or managing cases by themselves. And the good thing is, nowadays, it’s easier to connect with a community for support and advice than it was before. I think that doing my best to rely on a support network and not letting judgment or ego cloud my vision played an important role in my journey.
It’s also crucial to focus on the patients’ best interest and acknowledge when your skills might not yet match their needs. Sometimes you’ll need to refer a patient to a colleague who’s more comfortable with their case. Or you can work with them—taking on cases alongside more experienced colleagues, like double scrubbing on complex cases like CTOs, can be incredibly beneficial for both the doctor and the patient. This is my point of view since I moved to private practice a few years ago.
Do you have a go-to algorithm when it comes to treating challenging calcific plaque from an interventional perspective?
Our approach, especially regarding tools, has evolved recently. Intravascular lithotripsy (IVL) has become a significant asset and made certain procedures more easily accessible. The algorithm is essentially the one Dr. Kevin Croce put up on Twitter.
Intravascular imaging is crucial in my practice – it’s used in about 99% of cases, especially with calcified complex lesions. It guides us in assessing lesion length, arc of calcification, and depth. Although I don’t have optical coherence tomography (OCT), which makes depth assessment a bit challenging, I rely on Intravascular Ultrasound (IVUS).
For cases where I can't deliver a balloon, rotational atherectomy (ROTA) is my first step for modifying the lesion. If it’s circumferential calcium, I tend to use IVL. For larger vessels with nodular calcium, I often use more orbital atherectomy, especially in the left main artery or bifurcation. Following atherectomy, I do imaging post-ballooning. Checking results with intracoronary imaging using IVUS is a standard practice for me at the end of the case to confirm appropriate stent expansion and optimization, as we often see patients return with issues in calcified lesions that were not optimally treated.
As an attending working at a practice, unlike when I was a trainee, I follow patients long-term. This ongoing care has shown me how treatments done years ago might require modifications, especially if they’d been done suboptimally. It’s all part of the learning process in medical practice. We often find ourselves modifying earlier work with newer techniques like laser atherectomy, IVL, and in some cases, brachytherapy or even bypass. You realize that there are certain things that you may have done differently had you known what you know now. That's why they call it practice; you’re literally learning from each experience.
When thinking about the business of healthcare, are there a couple of concepts that you wish you understood better coming out of fellowship?
I’ve given this quite a bit of thought. Your perspective shifts over time, and it’s interesting to compare where I am now to where I was ten years ago. I spent about five and a half years in academia and have been in private practice for three years. I think when I came out, I was operating on my survival instincts, both for myself and my patients. I wasn’t thinking much about program development or resource management; those came with time.
In any system, dealing with administrators is inevitable, and no one really teaches you how to navigate those conversations. I think it’s fortunate to have an administrator who is motivated to develop programs. They, from my experience, operate on a two-year cycle, focusing on short-term gains for their specific service line. They’re often looking to move up to the next level after showing some profit or benefit within that period. That's just the way that their cycle goes—and I wasn’t aware of it until much later. This mindset doesn’t usually align with the long-term sustainability of a program. The easiest way in any industry to show profit is by cutting costs, which doesn’t always align with the needs of a healthcare program, like acquiring new technology or equipment. Their decisions are often dictated by the budget, which is randomly, arbitrarily set and governed by the focus of being budget positive, not necessarily on net positivity.
This entire concept was hard for me to accept initially because my primary concern was patient care, which sometimes required expensive resources. It was eye-opening to understand the financial perspective behind decisions like starting an ECMO program. The administrative approach often differs significantly from how I would manage my finances – it's all about the budget within their two-year cycle, not necessarily about what's coming in and going out.
So, understanding the incentives of the people you're working with is critical?
Absolutely. I think in business, having a long-term perspective is key, especially when you're committed to staying in the same practice or city. You're in it for the long haul with your patients, who aren't on a two-year cycle like many administrators. They're more likely on a 10-year cycle or longer. So I think it's important to have transparent, though not confrontational, conversations, understanding where the administrators are coming from while keeping your goals and your patient’s goals in mind. These conversations will help you find a common ground.
However, finding common ground might not lead to immediate results, but it's about making progress, however slow it might be. No negotiation yields everything you want right away. It's a gradual process, slower than most expect coming out of training. So why is it taking so long to make a change? It takes time because people's priorities are different.
Dr. Ravi Hira is a well-published interventional cardiologist specializing in complex coronary disease, offering treatment options for patients who may not be surgical candidates. Dr. Hira currently practices at the Pulse Heart Institute and serves as Director of the Cardiac Care Outcomes Assessment Program (COAP) in Seattle, WA. In this interview, Dr. Hira shares his journey in the field of medicine with an emphasis on personal growth, autonomy, community, and passion for his work.
Shortly after you completed your fellowship training, was there a therapy area or subject matter you wish you were taught or had more experience in?
It’s been almost 10 years since I graduated in 2015, and a lot has changed since then.
I trained in Houston, Texas, a city heavily focused on surgical treatment of complex CAD. So we didn't really do much complex percutaneous coronary interventions (PCI), to be honest. I had a bit of exposure to atherectomy and some Impella and mechanical circulatory support, but only very minimal exposure to chronic total occlusions (CTOs) or complex coronary training. The more complex cases were typically referred to surgery, and surgeons were quite aggressive in taking those on. Then, when I moved to Washington for my first job post-training, I noticed that we were dealing with an older patient population, many over 70 or 80, who were being turned down for surgery. These patients ended up in our care, which meant I had to really step up my skills in complex coronary procedures.
Although I had attended conferences and meetings where these cases were discussed and demonstrated, I didn’t have much first-hand experience with them myself. It was only when I began practicing that I fully realized the extent of this gap in my experience.
I found myself looking at cases that, during my training, would have been referred to surgery – but now, these cases were being sent back to us, either not fully treated or simply turned down by surgeons. It brought me to a crucial question: what should I do with these patients, and how could I enhance my skills to serve them better?
If I'm a fellow nearing the end of training or early in my career, what are one or two immediate steps I can take to steepen my learning curve in complex PCI?
Back in 2015, when I was getting into this, the term “complex PCI” wasn’t widely recognized. CHIP was just emerging, but things are very different now. Back then, online resources – like Twitter for example – weren’t readily available with this kind of information. There wasn’t a dedicated fellowship or specialized training in complex coronary work. I learned a lot of this on the job later in my career. There was a growing awareness of the diversification in interventional cardiology, with many leaning towards structural work. Quite a few of my co-fellows chose to pursue structural cardiology directly in their jobs. At the time, the focus was more on procedures like TAVR, but discussions about Mitral procedures were not as common. There was a sentiment that if you've already been trained, why spend another year on complex coronary?
Having seen the range and complexity of what can be done now, I’d say considering an additional year of training could be beneficial. If not, finding a role that offers on-the-job exposure with good mentorship is invaluable. It’s something I was lucky to stumble upon, although it wasn’t preplanned. Additionally, attending more meetings and actively engaging with the medical community is key. There’s a lot more visibility now about what others are doing, thanks to Twitter and live case streams or recorded procedures – where I learned a lot of tips and tricks. This access makes it easier to learn and apply new techniques. In the past, our network was limited to a handful of colleagues for case discussions. Now, you can reach out to a global community for feedback and advice, which is an incredible resource.
Many residents and fellows leave training with a sense that they aren’t fully ready for clinical practice. Do you remember a time when you felt like you weren’t prepared for “prime time”? How did you overcome this?
That’s a relatable feeling. When I finished my training, I certainly felt unprepared, beyond just the initial jitters of starting as a new attending. It was compounded by the responsibility of training fellows. It was challenging to balance guiding them while giving them enough freedom to learn through their own mistakes—as a result, in my early days as an attending, my evaluations weren’t that great. To be frank, I was seen as overly hands-on compared to more experienced colleagues who were just sitting in the control room and letting the fellows do what they do. I was the only interventionalist and cath lab director at my primary hospital, so it was a bit isolating without peers to consult on-site. In other words, if there was a complication, it was on me.
What helped me was talking to others and reaching out for help – it's an experience which everybody goes through in many different ways. I’ve never been one to let ego get in the way of admitting I don’t know something and asking for guidance or help.
Some people come out of training feeling overly confident. They think they are God's gift to interventional cardiology. But that’s fundamentally flawed and gets in their way of growth, evolution and serving their patients, to be honest.
I’m listening to an audio book titled Black Box Thinking by Matthew Syed—it was suggested by my mentor—which compares the airline industry to medicine and illustrates the importance of systematic learning from experiences. If you don't ask someone else to look at your case or to review things, you never get feedback. You can critique yourself only up to a point. For example, in the first few months after a few of my fellows graduated, they would call me on every complex case, then it gradually got less and less until they felt comfortable finding someone local or managing cases by themselves. And the good thing is, nowadays, it’s easier to connect with a community for support and advice than it was before. I think that doing my best to rely on a support network and not letting judgment or ego cloud my vision played an important role in my journey.
It’s also crucial to focus on the patients’ best interest and acknowledge when your skills might not yet match their needs. Sometimes you’ll need to refer a patient to a colleague who’s more comfortable with their case. Or you can work with them—taking on cases alongside more experienced colleagues, like double scrubbing on complex cases like CTOs, can be incredibly beneficial for both the doctor and the patient. This is my point of view since I moved to private practice a few years ago.
Do you have a go-to algorithm when it comes to treating challenging calcific plaque from an interventional perspective?
Our approach, especially regarding tools, has evolved recently. Intravascular lithotripsy (IVL) has become a significant asset and made certain procedures more easily accessible. The algorithm is essentially the one Dr. Kevin Croce put up on Twitter.
Intravascular imaging is crucial in my practice – it’s used in about 99% of cases, especially with calcified complex lesions. It guides us in assessing lesion length, arc of calcification, and depth. Although I don’t have optical coherence tomography (OCT), which makes depth assessment a bit challenging, I rely on Intravascular Ultrasound (IVUS).
For cases where I can't deliver a balloon, rotational atherectomy (ROTA) is my first step for modifying the lesion. If it’s circumferential calcium, I tend to use IVL. For larger vessels with nodular calcium, I often use more orbital atherectomy, especially in the left main artery or bifurcation. Following atherectomy, I do imaging post-ballooning. Checking results with intracoronary imaging using IVUS is a standard practice for me at the end of the case to confirm appropriate stent expansion and optimization, as we often see patients return with issues in calcified lesions that were not optimally treated.
As an attending working at a practice, unlike when I was a trainee, I follow patients long-term. This ongoing care has shown me how treatments done years ago might require modifications, especially if they’d been done suboptimally. It’s all part of the learning process in medical practice. We often find ourselves modifying earlier work with newer techniques like laser atherectomy, IVL, and in some cases, brachytherapy or even bypass. You realize that there are certain things that you may have done differently had you known what you know now. That's why they call it practice; you’re literally learning from each experience.
When thinking about the business of healthcare, are there a couple of concepts that you wish you understood better coming out of fellowship?
I’ve given this quite a bit of thought. Your perspective shifts over time, and it’s interesting to compare where I am now to where I was ten years ago. I spent about five and a half years in academia and have been in private practice for three years. I think when I came out, I was operating on my survival instincts, both for myself and my patients. I wasn’t thinking much about program development or resource management; those came with time.
In any system, dealing with administrators is inevitable, and no one really teaches you how to navigate those conversations. I think it’s fortunate to have an administrator who is motivated to develop programs. They, from my experience, operate on a two-year cycle, focusing on short-term gains for their specific service line. They’re often looking to move up to the next level after showing some profit or benefit within that period. That's just the way that their cycle goes—and I wasn’t aware of it until much later. This mindset doesn’t usually align with the long-term sustainability of a program. The easiest way in any industry to show profit is by cutting costs, which doesn’t always align with the needs of a healthcare program, like acquiring new technology or equipment. Their decisions are often dictated by the budget, which is randomly, arbitrarily set and governed by the focus of being budget positive, not necessarily on net positivity.
This entire concept was hard for me to accept initially because my primary concern was patient care, which sometimes required expensive resources. It was eye-opening to understand the financial perspective behind decisions like starting an ECMO program. The administrative approach often differs significantly from how I would manage my finances – it's all about the budget within their two-year cycle, not necessarily about what's coming in and going out.
So, understanding the incentives of the people you're working with is critical?
Absolutely. I think in business, having a long-term perspective is key, especially when you're committed to staying in the same practice or city. You're in it for the long haul with your patients, who aren't on a two-year cycle like many administrators. They're more likely on a 10-year cycle or longer. So I think it's important to have transparent, though not confrontational, conversations, understanding where the administrators are coming from while keeping your goals and your patient’s goals in mind. These conversations will help you find a common ground.
However, finding common ground might not lead to immediate results, but it's about making progress, however slow it might be. No negotiation yields everything you want right away. It's a gradual process, slower than most expect coming out of training. So why is it taking so long to make a change? It takes time because people's priorities are different.
Fun, Insightful Interviews with the
World's Brightest Physicians
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Fun, Insightful Interviews with the
World's Brightest Physicians
Delivered straight to your inbox. Completely free. No spam.
Fun, Insightful Interviews with the
World's Brightest Physicians
Delivered straight to your inbox. Completely free. No spam.
How crucial has networking and building relationships been for you, both within interventional cardiology and in a broader, multidisciplinary context?
It all boils down to community. We're all human beings and we all need a sense of belonging, whether that’s with colleagues in our practice, specialists in different fields, or others sharing a general interest in healthcare. Being part of a community is vital for my mental well-being and helps me stay engaged with my work. Sometimes, stepping out of your immediate circle to interact with professionals like vascular or cardiac surgeons brings new perspectives, changing how you approach situations. I don't have a problem picking up the phone and calling somebody and asking, ‘Hey, can we talk through this? Educate me. What am I not seeing? What am I not understanding?’ Or ‘This is where I'm coming from. What exactly is driving your thinking behind this particular case?’
In my situation, my parents have been in academia their entire lives. They're both physicians. I initially followed in their footsteps in academia, and was successful at it, too–with promotions and so on. However, I realized I wasn’t completely satisfied. I had taken on a role as a medical director at the Cardiac Care Outcomes Assessment program, a cardiovascular quality improvement collaborative in Washington, as part of my academic duties to publish and do more PCI work. There, I interacted with a diverse range of professionals, general cardiologists, electrophysiologists, cardiac surgeons, and administrators from all different systems and hospitals in Washington, which was eye-opening. The conversations made me reassess what I really needed for my happiness and career satisfaction.
During a holiday get-together, an EP doctor on the committee suggested I come interview with them. Initially, I was hesitant about private practice, but he encouraged me to just have a conversation, asking what I had to lose. I discovered that there was a lot more research and trial recruitment happening in private hospitals and practices than I had been able to achieve in my academic role. These serendipitous interactions made me realize the value of being open to new opportunities and the unexpected turns life can take.
Your needs and desires are going to change as your career evolves. I've learned that the more rigidly you cling to the story you’re telling yourself the less likely you are to find true happiness. You need to be open to the random experiences life brings.
When you think about your transition from academia to private practice, how did you navigate evaluating different opportunities, particularly in terms of negotiating salaries, perks, and other factors? Could you share insights for those who are new to this process?
My experience was different from our graduating fellows, as I initially wanted a position in academia – which is sparse in interventional cardiology. You get sent to satellite hospitals, hoping to eventually build a practice that way over time.
When fellows graduate, what I notice is they bring an Excel spreadsheet to compare practices on criteria like salary, lab time, vacation allowances, how near it is to their home or preferred geographic location, and opportunities for continued education. In this sense, it’s as if they viewed all practices as being the same, and chose based on perks.
But how about starting with what you actually value?
Many get caught up in financial considerations, especially those who come out of a long fellowship with a lot of debt. Obviously, that’s an important issue. But I don’t think it matters as much 25-30 years down the road. The difference of a few thousands or hundreds of thousands a year may not be as much as you think - it doesn’t change your happiness level beyond a certain minimum amount. What’s more likely to make you happy is your colleagues and the practice’s culture. If you find people that value the same types of things, you're more likely to be satisfied.
When I was job hunting, I chose a practice that had grown but maintained a core group of people who had stayed throughout their careers with no intention of leaving. That tells you that there's some secret sauce there. When you lose the human connection, you burn out, and then think that the job is the problem and start changing positions. For me, finding a workplace that felt like a second family was important. You spend more time with your colleagues than anybody else. The nature of those relationships was more important to me than the money and the vacation days.
The other important thing is autonomy. Having control over your schedule, like deciding when to take vacations, is immensely valuable. As an adult and hardworking physician, having to take permission from others about vacation days and other such things isn’t ideal. You might make less money but this type of autonomy over your schedule is much more important than salary or CME. Such an understanding among colleagues is rare. You need to be able to balance your professional life with your personal life – I want to spend time with my kids when they're young, for example. And the more you expand on other aspects of your life— develop hobbies, even—the better a physician you become. Your brain is a little bit more open to other experiences and it feeds back into your satisfaction as a physician.
Do you listen to music in the cath lab? If so, are there a couple of top songs that you play on repeat?
I don't really listen to music. I meditate regularly as part of my routine, not specifically before procedures, though. I've noticed that the music playing in the background can affect my heart rate, and I don't like my heart rate too fast. If I find my heart rate going up over 70 bpm or so during a procedure, it’s usually due to the music. I ask them to change it to something more mellow like Coldplay or Bruno Mars.
How about movies – what are your top 3 favorites of all time?
There's only one that I could think of that I remember from when I was a kid, ‘Braveheart’. But with my kids, one of their favorites is ‘Inside Out’ – a Disney Pixar movie – and I loved it, it’s really interesting. Another one I enjoyed is a Disney short called ‘Float’, which is literally less than 10 minutes, but a really interesting story nonetheless.
If you could go back to your late 20s, what would you tell your younger self from a professional standpoint?
A philosophical, reflective question, right? Honestly, I don’t think I’d be who I am and where I am today without having gone through those experiences, for better or for worse. I still have a long way to go, of course. But if I had to pick one thing, it would probably be to trust myself more. Sometimes, like I said, we get caught up in being overly analytical, like we’re living our lives on an Excel spreadsheet, following what our brains dictate. But there are times when it's crucial to just follow your gut instinct. That’s something I’ve come to understand and value more recently.
Are there any upcoming conferences or clinical research or anything else that you'd like to raise awareness for or mention?
There are some sensitive issues, like the situation in Gaza, that many physicians are concerned about but often go unmentioned. Nobody wants to put that up on social media or say anything about it, which is part of the problem. I've been contributing to Doctors Without Borders in response to these issues, so people who’d like to make a donation can.
How crucial has networking and building relationships been for you, both within interventional cardiology and in a broader, multidisciplinary context?
It all boils down to community. We're all human beings and we all need a sense of belonging, whether that’s with colleagues in our practice, specialists in different fields, or others sharing a general interest in healthcare. Being part of a community is vital for my mental well-being and helps me stay engaged with my work. Sometimes, stepping out of your immediate circle to interact with professionals like vascular or cardiac surgeons brings new perspectives, changing how you approach situations. I don't have a problem picking up the phone and calling somebody and asking, ‘Hey, can we talk through this? Educate me. What am I not seeing? What am I not understanding?’ Or ‘This is where I'm coming from. What exactly is driving your thinking behind this particular case?’
In my situation, my parents have been in academia their entire lives. They're both physicians. I initially followed in their footsteps in academia, and was successful at it, too–with promotions and so on. However, I realized I wasn’t completely satisfied. I had taken on a role as a medical director at the Cardiac Care Outcomes Assessment program, a cardiovascular quality improvement collaborative in Washington, as part of my academic duties to publish and do more PCI work. There, I interacted with a diverse range of professionals, general cardiologists, electrophysiologists, cardiac surgeons, and administrators from all different systems and hospitals in Washington, which was eye-opening. The conversations made me reassess what I really needed for my happiness and career satisfaction.
During a holiday get-together, an EP doctor on the committee suggested I come interview with them. Initially, I was hesitant about private practice, but he encouraged me to just have a conversation, asking what I had to lose. I discovered that there was a lot more research and trial recruitment happening in private hospitals and practices than I had been able to achieve in my academic role. These serendipitous interactions made me realize the value of being open to new opportunities and the unexpected turns life can take.
Your needs and desires are going to change as your career evolves. I've learned that the more rigidly you cling to the story you’re telling yourself the less likely you are to find true happiness. You need to be open to the random experiences life brings.
When you think about your transition from academia to private practice, how did you navigate evaluating different opportunities, particularly in terms of negotiating salaries, perks, and other factors? Could you share insights for those who are new to this process?
My experience was different from our graduating fellows, as I initially wanted a position in academia – which is sparse in interventional cardiology. You get sent to satellite hospitals, hoping to eventually build a practice that way over time.
When fellows graduate, what I notice is they bring an Excel spreadsheet to compare practices on criteria like salary, lab time, vacation allowances, how near it is to their home or preferred geographic location, and opportunities for continued education. In this sense, it’s as if they viewed all practices as being the same, and chose based on perks.
But how about starting with what you actually value?
Many get caught up in financial considerations, especially those who come out of a long fellowship with a lot of debt. Obviously, that’s an important issue. But I don’t think it matters as much 25-30 years down the road. The difference of a few thousands or hundreds of thousands a year may not be as much as you think - it doesn’t change your happiness level beyond a certain minimum amount. What’s more likely to make you happy is your colleagues and the practice’s culture. If you find people that value the same types of things, you're more likely to be satisfied.
When I was job hunting, I chose a practice that had grown but maintained a core group of people who had stayed throughout their careers with no intention of leaving. That tells you that there's some secret sauce there. When you lose the human connection, you burn out, and then think that the job is the problem and start changing positions. For me, finding a workplace that felt like a second family was important. You spend more time with your colleagues than anybody else. The nature of those relationships was more important to me than the money and the vacation days.
The other important thing is autonomy. Having control over your schedule, like deciding when to take vacations, is immensely valuable. As an adult and hardworking physician, having to take permission from others about vacation days and other such things isn’t ideal. You might make less money but this type of autonomy over your schedule is much more important than salary or CME. Such an understanding among colleagues is rare. You need to be able to balance your professional life with your personal life – I want to spend time with my kids when they're young, for example. And the more you expand on other aspects of your life— develop hobbies, even—the better a physician you become. Your brain is a little bit more open to other experiences and it feeds back into your satisfaction as a physician.
Do you listen to music in the cath lab? If so, are there a couple of top songs that you play on repeat?
I don't really listen to music. I meditate regularly as part of my routine, not specifically before procedures, though. I've noticed that the music playing in the background can affect my heart rate, and I don't like my heart rate too fast. If I find my heart rate going up over 70 bpm or so during a procedure, it’s usually due to the music. I ask them to change it to something more mellow like Coldplay or Bruno Mars.
How about movies – what are your top 3 favorites of all time?
There's only one that I could think of that I remember from when I was a kid, ‘Braveheart’. But with my kids, one of their favorites is ‘Inside Out’ – a Disney Pixar movie – and I loved it, it’s really interesting. Another one I enjoyed is a Disney short called ‘Float’, which is literally less than 10 minutes, but a really interesting story nonetheless.
If you could go back to your late 20s, what would you tell your younger self from a professional standpoint?
A philosophical, reflective question, right? Honestly, I don’t think I’d be who I am and where I am today without having gone through those experiences, for better or for worse. I still have a long way to go, of course. But if I had to pick one thing, it would probably be to trust myself more. Sometimes, like I said, we get caught up in being overly analytical, like we’re living our lives on an Excel spreadsheet, following what our brains dictate. But there are times when it's crucial to just follow your gut instinct. That’s something I’ve come to understand and value more recently.
Are there any upcoming conferences or clinical research or anything else that you'd like to raise awareness for or mention?
There are some sensitive issues, like the situation in Gaza, that many physicians are concerned about but often go unmentioned. Nobody wants to put that up on social media or say anything about it, which is part of the problem. I've been contributing to Doctors Without Borders in response to these issues, so people who’d like to make a donation can.
How crucial has networking and building relationships been for you, both within interventional cardiology and in a broader, multidisciplinary context?
It all boils down to community. We're all human beings and we all need a sense of belonging, whether that’s with colleagues in our practice, specialists in different fields, or others sharing a general interest in healthcare. Being part of a community is vital for my mental well-being and helps me stay engaged with my work. Sometimes, stepping out of your immediate circle to interact with professionals like vascular or cardiac surgeons brings new perspectives, changing how you approach situations. I don't have a problem picking up the phone and calling somebody and asking, ‘Hey, can we talk through this? Educate me. What am I not seeing? What am I not understanding?’ Or ‘This is where I'm coming from. What exactly is driving your thinking behind this particular case?’
In my situation, my parents have been in academia their entire lives. They're both physicians. I initially followed in their footsteps in academia, and was successful at it, too–with promotions and so on. However, I realized I wasn’t completely satisfied. I had taken on a role as a medical director at the Cardiac Care Outcomes Assessment program, a cardiovascular quality improvement collaborative in Washington, as part of my academic duties to publish and do more PCI work. There, I interacted with a diverse range of professionals, general cardiologists, electrophysiologists, cardiac surgeons, and administrators from all different systems and hospitals in Washington, which was eye-opening. The conversations made me reassess what I really needed for my happiness and career satisfaction.
During a holiday get-together, an EP doctor on the committee suggested I come interview with them. Initially, I was hesitant about private practice, but he encouraged me to just have a conversation, asking what I had to lose. I discovered that there was a lot more research and trial recruitment happening in private hospitals and practices than I had been able to achieve in my academic role. These serendipitous interactions made me realize the value of being open to new opportunities and the unexpected turns life can take.
Your needs and desires are going to change as your career evolves. I've learned that the more rigidly you cling to the story you’re telling yourself the less likely you are to find true happiness. You need to be open to the random experiences life brings.
When you think about your transition from academia to private practice, how did you navigate evaluating different opportunities, particularly in terms of negotiating salaries, perks, and other factors? Could you share insights for those who are new to this process?
My experience was different from our graduating fellows, as I initially wanted a position in academia – which is sparse in interventional cardiology. You get sent to satellite hospitals, hoping to eventually build a practice that way over time.
When fellows graduate, what I notice is they bring an Excel spreadsheet to compare practices on criteria like salary, lab time, vacation allowances, how near it is to their home or preferred geographic location, and opportunities for continued education. In this sense, it’s as if they viewed all practices as being the same, and chose based on perks.
But how about starting with what you actually value?
Many get caught up in financial considerations, especially those who come out of a long fellowship with a lot of debt. Obviously, that’s an important issue. But I don’t think it matters as much 25-30 years down the road. The difference of a few thousands or hundreds of thousands a year may not be as much as you think - it doesn’t change your happiness level beyond a certain minimum amount. What’s more likely to make you happy is your colleagues and the practice’s culture. If you find people that value the same types of things, you're more likely to be satisfied.
When I was job hunting, I chose a practice that had grown but maintained a core group of people who had stayed throughout their careers with no intention of leaving. That tells you that there's some secret sauce there. When you lose the human connection, you burn out, and then think that the job is the problem and start changing positions. For me, finding a workplace that felt like a second family was important. You spend more time with your colleagues than anybody else. The nature of those relationships was more important to me than the money and the vacation days.
The other important thing is autonomy. Having control over your schedule, like deciding when to take vacations, is immensely valuable. As an adult and hardworking physician, having to take permission from others about vacation days and other such things isn’t ideal. You might make less money but this type of autonomy over your schedule is much more important than salary or CME. Such an understanding among colleagues is rare. You need to be able to balance your professional life with your personal life – I want to spend time with my kids when they're young, for example. And the more you expand on other aspects of your life— develop hobbies, even—the better a physician you become. Your brain is a little bit more open to other experiences and it feeds back into your satisfaction as a physician.
Do you listen to music in the cath lab? If so, are there a couple of top songs that you play on repeat?
I don't really listen to music. I meditate regularly as part of my routine, not specifically before procedures, though. I've noticed that the music playing in the background can affect my heart rate, and I don't like my heart rate too fast. If I find my heart rate going up over 70 bpm or so during a procedure, it’s usually due to the music. I ask them to change it to something more mellow like Coldplay or Bruno Mars.
How about movies – what are your top 3 favorites of all time?
There's only one that I could think of that I remember from when I was a kid, ‘Braveheart’. But with my kids, one of their favorites is ‘Inside Out’ – a Disney Pixar movie – and I loved it, it’s really interesting. Another one I enjoyed is a Disney short called ‘Float’, which is literally less than 10 minutes, but a really interesting story nonetheless.
If you could go back to your late 20s, what would you tell your younger self from a professional standpoint?
A philosophical, reflective question, right? Honestly, I don’t think I’d be who I am and where I am today without having gone through those experiences, for better or for worse. I still have a long way to go, of course. But if I had to pick one thing, it would probably be to trust myself more. Sometimes, like I said, we get caught up in being overly analytical, like we’re living our lives on an Excel spreadsheet, following what our brains dictate. But there are times when it's crucial to just follow your gut instinct. That’s something I’ve come to understand and value more recently.
Are there any upcoming conferences or clinical research or anything else that you'd like to raise awareness for or mention?
There are some sensitive issues, like the situation in Gaza, that many physicians are concerned about but often go unmentioned. Nobody wants to put that up on social media or say anything about it, which is part of the problem. I've been contributing to Doctors Without Borders in response to these issues, so people who’d like to make a donation can.
